COVID 19 – Easing up on lockdown measures. Are we there yet?
COVID 19 a global pandemic
On 30 January 2020, the World Health Organisation (WHO) declared COVID 19 a Public Health Emergency of International Concern.
By 11 March 2020, with many countries reporting confirmed cases and rising fatalities, the WHO declared COVID 19 a global pandemic.
Governments were urged repeatedly by the WHO to take this outbreak seriously to take strong and early interventions to stop the spread of this virus. The WHO warned that for some countries, the window for these actions was closing. Unfortunately for countries like Italy, Spain, and now the USA, the speed of infections had a deceiving slow start but became exponential before the warnings were heeded. As a result, their overwhelm health system struggled to cope with seriously ill patients. By late March 2020, the thousands of COVID 19 fatalities in Italy, Spain, and the USA exceeded that of China.
Interventions to combat pandemic
Plans to combat the global pandemic requires a comprehensive package of interventions. The three anchors of this package are:
- Develop and mass vaccinate populations to provide population-level protection.
- Develop and use effective treatments from re-purposed and new drugs as well as the use of blood plasma from recovered patients.
- Non pharmaceutical interventions (NPIs).
Vaccines and treatments
With the novel SARS-CoV-2 virus responsible for COVID 19, interventions (1) and (2) are not immediately available. In the case of vaccines for COVID 19, there are unprecedented cooperation globally, advances in development platforms, and multiple clinical trials well underway. However, many experts agree that an effective and safe vaccine will not be available for at least another eighteen months.
There is some hope for a faster time frame for treatment options, especially from re-purposed drugs. Re-purposed drugs are those that were developed to treat other diseases but have chemical ingredients that could be effective in treating new diseases. Clinical trials have started to re-purpose drugs such as chloroquine and its derivative hydroxychloroquine, remdesivir, and Interferon beta.
In the meantime, governments have to rely on NPIs to identify, isolate, and slow down the spread of this virus. How well governments implement different combinations of NPIs will decide the scale of infections and fatalities from COVID 19.
Non pharmaceutical interventions (NPIs)
The explicit purposes of non-pharmaceutical interventions (NPIs) are to identify, contain, slow down, and, where possible, stop the spread of this virus.
NPIs implemented around the world can be categorized into:
- Identify and trace suspect cases and those in close contact with suspect case
- Isolation of confirmed cases
- Quarantine suspect cases & close contacts of confirmed cases
- Social distancing
- Closing borders to non-citizens and residents
- Control & restrictions of the population – the size of gatherings, restrict operating hours.
- Lockdowns of the population – closing schools, universities, places of work, social, religious & sports events
With the novel SARS-CoV-2 virus, there are still many unknowns, including the effectiveness of NPIs. To maximizing the potential impact of NPIs, countries implementation plan needs to have the following features:
- taking an integrated system approach across all elements of NPIs
- rigor, pace, urgency, and attention to details in execution
- ability to pivot, adjust, scale up or down
- thorough and robust case management of suspect and confirmed cases
- access to timely and comprehensive intelligence from rigorous testing data
High social and economic costs of NPIs – a necessary step
Epidemiological models like the Imperial College COVID Response Team report points to an unacceptable loss of lives if governments do not take early and comprehensive NPIs. Since early March 2020, governments started introducing tougher and tougher NPIs when isolation and quarantine of confirm and suspect cases was no longer sufficient. For countries like Italy and Spain, these drastic NPIs came too late for the first wave of this pandemic. Their confirmed cases and fatalities rose exponentially and exceeded China.
It would appear that the UK and the USA also waited too long before they acted. Rising confirmed cases and fatalities would suggest that they may also have just missed the boat for the first wave of this pandemic. Meanwhile, countries like New Zealand and Australia are hoping that their mid-March 2020 nationwide lockdown and total border closure would be enough to “flatten the curve” of the first wave of this pandemic. These two countries do not have long to wait for the verdict on whether they have acted on time.
A new norm – a cycle of easing back and scaling up NPIs
Even with a vaccine, COVID 19, if it behaves like its cousin, the common flu, is here to stay. Governments will need to accept a new norm of easing back and scaling up NPIs to manage future community outbreaks of COVID 19.
Knowing when to start and end current and future NPI programs will be a difficult and finely balanced decision-making process for governments. The immediate trade-offs will be between saving lives and the economy. Ease back too early, COVID 19 comes back with a vengeance. Ease back too late, economic and social recovery becomes even more difficult.
Are we there yet?
For some governments, the first of many similar decisions will need to be made by mid-April 2020. They will want to know whether their NPIs programs have successfully got COVID 19 under control.
Is the rate of new cases trending down? This is the common question asked by governments. If so, governments will assume that they have flattened the curve of the first wave of this pandemic.
That question can be answered with a high degree of confidence provided there is a rigorous, comprehensive, timely, and thorough testing program. Governments need to reassure themselves that their testing program is robust enough to provide reliable answers to that most crucial question.
Test, test, test
“Until we have an effective vaccine, keeping the infections to less than 1% of the population is essentially down to two things. Isolation and testing – Bill Gates.”
In mid-March 2020, the Director-General of the WHO, Dr. Tedros Adhanom Ghebreyesus, reminded governments to take a comprehensive approach to break the transmission chain. Testing and isolation are the two pillars of this comprehensive approach. Test to identify and isolate suspect cases, contact trace to identify contacts, and tests them as well. Dr. Tedros was concern that governments were not testing enough. Without adequate testing, the effectiveness of all other interventions, such as isolation and contact tracing, is diminished. He makes what is now a quotation for this pandemic response – “Test, Test, Test.”
The two main tests to detect COVID 19 infection are a PCR (polymerase chain reaction] test and an antibody test. The former looks for viral RNA to confirm whether a person is infected. The latter is a blood test to detect antibodies produced to combat the invading virus in the body.
Capacity and capability
When dealing with this virus, every week counts. The SARS-Cov-2 virus is spreading at an exponential rate, and countries need insights and intelligence from a rigorous, comprehensive, and timely testing program. With few exceptions most countries start off with inadequate testing. Two of the most common reasons for lack of testing are:
- laboratory capacity and capability constraints
- too narrow criteria for accepting test requests
Most countries have taken too long to scale up their health system’s testing capacity and capability. The protocols for scaling up conventional laboratory capacity and capability, especially if private laboratories are involved, can take weeks of negotiations to agree on test specifications, reporting requirements, volumes, prices, and contracts. These same countries are dragging the chain in exploring new point of care testing that can provide answers in hours rather than days.
The exceptions are countries like South Korea and Singapore. Learning from previous epidemics and pandemics like SARs, swine flu, and MERs, investments in rapid testing capacity and capability have been organized well in advance. Mobile testing booths and drive throughs (South Korea), hundreds of community fever clinics (Singapore) were on standby well before the first case hit their shores.
This is a crucial lesson that other countries need to learn to prepare for future pandemics.
Criteria for testing
Another common limiting factor for more testing is the criteria to accept testing requests. In many countries, testing is done when someone has symptoms. Experts now accept that asymptomatic and pre-symptomatic people are infectious. Asymptomatic cases are those infected and infectious without showing any symptoms such as cough and fever. Pre-symptomatic cases are those infected and infectious before symptoms developed a few days later.
Recent World Economic Forum article1 reports that at least 60% of people infected show mild or no symptoms. Data from China, Iceland, South Korea, Japan and the CDC2 provides further confirmation that asymptomatic and pre-symptomatic cases are infectious and can transmit the virus to others. On 28 February 2020, the NEJM published an article by Bill Gates stating that people who are just mildly ill or even pre-symptomatic are silent transmitters.
At the beginning of this pandemic, understandably testing criteria were restricted to a suspect case with symptoms. This is no longer appropriate, and testing criteria need to be widened beyond symptomatic cases. Otherwise, this virus will continue to spread undetected in the community until symptoms appear. By then, the numbers infected could reach exponential numbers that will overwhelm a country’s health system.
Clear and present danger – under reporting of new cases
The trend of new cases detected is a crucial indicator for many countries. Governments rely on this indicator in deciding how long to maintain lockdowns and other strong NPI measures.
Any country that only tests symptomatic cases are under-reporting new cases. Therefore, any cluster of asymptomatic and pre-symptomatic will be undetected until it’s too late. Under reporting of new cases will almost certainly paint a rosy picture that the curve has been flattened. This could lead government to prematurely and wrongly ease back on their NPI measures that will have fatal and devastating consequences.
Confusion in the numbers – another clear and present danger
Countries are reporting key headline numbers like the number of people tested, the number of new cases, number of people recovered, number of deaths, the number of tests done, number of test capacity.
All of these have different meanings and provide different insights.
For clarity here is a definition of these four different numbers:
- Test capacity is the maximum number of tests that can be done. There are three test capacity points – capacity to collect specimens, the capacity to process specimens, and the capacity to report on results.
- The test done is the number of tests that have completed the above three steps.
- Number of people tested is the number of all people tested
- Number of new cases tested is the number of new people tested, a subset of (3)
A useful guide on how to use these numbers are as follows:
- Total test done will always be higher than total number of people tested. Typically, a susp person can have more than one test before being confirmed as positive or negative.
- Total number of people tested comprises both new and existing confirmed cases.
- Total number of people tested can be analyzed into
- Confirm negative
- Waiting for results
- Positive & actively being treated
- Positive & discharged
- Positive & died
- Total number of new people tested will be a subset of (2)
Focus on the number of people not the number of tests
Governments should focus on two percentages – (1) People tested positive as a percentage of total number of people tested (2) People tested waiting for results as a percentage of total number of people tested. Both these percentages should be trending down if things are going well. Here is an example of the cumulative number on people/cases tested for South Korea for 1 April 2020
YTD number of people/cases 421,547
- Total people/cases with negative results (395,075)
- Total number of people tested waiting for the result (16,585)
- Total number of people tested & confirm positive (9,887)
Of the 9,887 people tested & confirmed positive:
- These people have died (165)
- These people have recovered (5,567)
- These people are still under active care (4,155)
People tested positive as a % of total people tested – 2.34%
People tested waiting for results as a % of total people tested – 3.9%
There is clear and present danger when governments make crucial decisions either without understanding what these numbers mean or deliberately misusing them to suit their other agendas. One of the most glaring example is to declare success because fewer new cases have been detected from an increase in number of tests done. Anybody see why this is incorrect?
Final word – no room for complacency
Together with South Korea, Singapore is considered an exemplar that has managed the first wave of this pandemic better than most. On 4 April 2020, with daily new cases trending in the wrong direction, Singapore’s government decided on a decisive and further restrictive package of NPIs. This latest move by Singapore shows that no country can be complacent. Strategies has to be constantly reviewed and plans changed decisively based on the latest information.
With this pandemic, there is no room for complacency. Poor decisions by governments based on erroneous, incomplete and out of date information will be paid for by increased infections and fatalities of its frontline first responders, health professionals, and the general population. So, get it right Presidents and Prime Ministers! If you get it wrong, you will be remembered as the person that at this crucial time failed your people, cause untold suffering and the death of thousands. If you get it right, it is why you took the high office – to protect and serve.
Note 1 – https://www.weforum.org/agenda/2020/03/people-with-mild-or-no-symptoms-could-be-spreading-covid-19/
Note 2 – https://www.sciencealert.com/here-s-what-we-know-so-far-about-those-who-can-pass-corona-without-symptoms/amp